Subject: [SHC] Dr. Gene Lindsey's Healthcare Musings Newsletter 22 June 2018

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22 June 2018

Dear Interested Readers,



I Believe In Atul

I was out for my afternoon walk on Wednesday listening to the Audiobook version of Jon Meacham’s The Soul of America: The Battle for Our Better Angels, and was thinking about my decision to write about how the Trump administration was quietly continuing its war on the achievements of the ACA, when my phone rang. The call was from my wife who had gone to Boston to do some errands, spend the night with a friend, and see her doctor at the Wellesley Atrius Health site early on Thursday. She was eager to let me know that she had just heard that Atul Gawande had been named as CEO for the new healthcare organization that is a joint venture between Amazon, Berkshire Hathaway and JP Morgan Chase. I was surprised at first and thought, “Atul is amazing, but he is not a medical manager. Why would he want this job?” Answering that question and exploring the hope of how someone of Atul Gawande’s knowledge, experience, and temperament might just be the answer to our prayers for a breakthrough that puts us back on course toward universal coverage and the Triple Aim was suddenly much more interesting than complaining about the president’s dark intentions to undermine healthcare.

I’ve read some of Atul’s books and almost all of his New Yorker articles. I have referred patients to his care for things as simple as a hernia repair and as delicate as a parathyroidectomy when we were both physicians in the same multispecialty practice. I am delighted to point to him along with Don Berwick, and Glenn Steele as former colleagues who, like me, learned important concepts and breathed the same air of quality, safety, and innovation in the learning environment that Robert Ebert created when he launched the Harvard Community Health Plan.

One of the best speeches I ever heard was the one he graciously gave at one of our annual awards banquets where he focused on “the difference between ignorance and ineptitude.” I am just an acquaintance from his past, but I fondly remember the big smile on his face when he walked across the baggage claim area in the New Orleans Airport several years ago just to say hello and introduce me to his son when he saw me traveling with one of my sons. His success in many different spheres greatly exceed the achievements of most of us in one sphere. One of my fantasies is that, like Superman, he really comes from a more advanced planet in another galaxy. He leads gently through his example as a practitioner, his willingness as a teacher to share what he has extracted from his reading and experience, and his insightful and inspiring prose. He is a connector of people and thoughts. When he speaks, people listen. In retrospect his choice to lead this new private effort of industry to improve health was a “no brainer.” If Elon Musk can get us all into space travel through the exercise of private enterprise, then perhaps Atul Gawande can lead us to universal care and the Triple Aim on a path through these three companies.

You may not know that there is a catalog of all of his writings from the New Yorker, Slate, and other publications that is available online. Any article that I mentioned below can be accessed through this resource. Through his writing the New Yorker has become a powerful voice in the debate about the future of healthcare. I think the New Yorker may have eclipsed the New England Journal of Medicine as a source for insightful articles about current issues and the future of healthcare because of Atul. His writing always builds on the lessons from the past, or what can be learned from data that we are collecting now. He has shown us that there is much to learn from how other industries manage complexity and safety. He is a believer in the benefits of both “low tech” and “high tech” innovations. He understands the necessity of disruption, but he also respects tradition.

I have many “favorite” Atul Gawande articles but when I heard of his new opportunity I immediately thought of the article that is probably my favorite, it is “Getting There From Here” written in 2009. I know that you may have a different favorite like “Cowboys and Pit Crews”, The “Cost Conundrum,” or the very powerfully written “The Hot Spotters”. Let me show you why “Getting There From Here” is an important article to remember as we think about what the choice of Atul Gawande might mean for all of us even though he will be working for Jeff Bezos, Warren Buffett, and Jamie Dimon.

Gawande begins the story with a profound observation:

In every industrialized nation, the movement to reform health care has begun with stories about cruelty...The stories become unconscionable in any society that purports to serve the needs of ordinary people, and, at some alchemical point, they combine with opportunity and leadership to produce change.

He was writing in 2009 as Congress was working on the ACA. He goes on to show how universal healthcare arose from patient concerns in Britain, France, Switzerland, and Canada and evolved out of the different systems that previously existed. In each case what happened was built on what previously existed when it became obvious to the public and to leadership that the status quo and the healthcare injustices that became motivating stories were no longer acceptable.

He adds more about the counter movements that have resisted change. Remember he wrote this article in 2009. It was prescient if you look back over the last eight years of Republican attack on the ACA that continues now in the form of President Trump’s “Association” plans, the undermining of Medicaid and Medicare, the reversal of the mandate, and the new legal uncertainty around coverage for preexisting conditions.

Yet wherever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy—a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse—especially for those who already have dependable coverage and access to good doctors and hospitals.

He covers a lot of history getting to his key point that the future will evolve from what exists now. This may not be good news for those whose opinions lie further left than his and look forward to abandoning what we have now for something new.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

He presents the concept of “path dependency” that drives a lot of outcomes like whether VHS or Beta would be the dominant format for video tape or whether IBM’s PCs would be the initial computer choice of most businesses over Apple’s products. Over many decades, indeed over almost two centuries, our path in healthcare has been a path of private ownership. Over the last seventy years it also been employer funded for most preretirement consumers and families. That is a hard path to exit. That is the same path that Atul will have an opportunity to widen and pave with the resources of Amazon, Berkshire Hathaway, and JP Morgan Chase. He supports the validity of “path dependency” as an important economic concept by pointing out that Paul Krugman won the Nobel Prize, as did John Nash (remember a “Beautiful Mind”), articulating examples and demonstrating the theory behind “path dependency.” Gawande uses history and economic principles to argue that because of “path dependency” we are unlikely to get on a different path than private care in our quest for universal access and the Triple Aim.

With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.

In retrospect the hope of the ACA was founded on this principle. It sought to continue the private delivery of care while expanding access through the public funding of those who were excluded from care by circumstances of poverty, previous illness, or the realities of difficult finance in the self insured market. He wrote when the last eight years were the future and not the past. I am sure that the ideas and the optimism that he expressed in 2009 are now buttressed by a clear analysis of what will work and what must be avoided as we continue our “path dependent” journey.

In designing this program, we’ll inevitably want to build on the institutions we already have. That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s).

When we live in confusing times our fears and worries are heightened when we look around and do not see credible leadership. Democrats don’t see credible leadership for the future of healthcare in the White House now, and Republicans did not see it when Barack Obama was the occupant. Perhaps we are looking for leadership in the wrong places when we look at the White House or at Capital Hill. Maybe a better place to look over the next few years will be Boston where Bezos, Buffett, and Dimon will be setting up Dr. Gawande with the resources necessary to shine some guiding light on the rest of the path that we all can follow. It will be an interesting process to observe. Gawande will not forget Don Berwick’s work and all the learning of the quality and safety efforts of the last quarter century. He has the advantage of age and experience. He is only 53 and has been thinking and working on the issues for over twenty years. He is a leader who has already made a big difference.

I think that he got off to a good start on the long journey ahead with his brief statement made at the time of the announcement of his new opportunity and challenge:

"I'm thrilled to be named CEO of this healthcare initiative. I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the U.S. and across the world. This work will take time but must be done. The system is broken, and better is possible."

Providing better care for everyone that lives here and expanding that expertise for the benefit of the world is a huge objective. Success would definitely make America great. Leadership is always core to the success of complex systems. There is reason to smile with renewed hope and expectations, and perhaps say a prayer of thanks on hearing of Atul’s opportunity to help all of us. It would be nice to think that Atul Gawande might enable all of us to enjoy better health at a sustainable expense before Elon Musk enables us to take long weekends in outer space.


Jon Meacham Hits The Nail on The Head

I am sure that I will be writing more about Jon Meacham’s book The Soul of America: The Battle for Our Better Angels. I had the surprisingly positive experience of hearing Meacham speak one evening last winter at the “Symphony Hall Speaker Series” in Boston. He is a Pulitzer Prize winning historian and the biographer of several presidents from Thomas Jefferson to George Herbert Walker Bush. He is also a professor at Vanderbilt, a journalist, and is a frequent commentator on news programs. To say the least he has a perspective on our times and the history and performance of the presidency. He is from Tennessee and neither a conservative or progressive, but honors tradition and can explain the past in a way that informs the moment. His thoughts should be useful to the entire political spectrum as long as that spectrum is made up of people that care about settled facts and want to see our democracy continue to move toward the promise that it has always pursued since its origin even through its failings and near death experiences.

Meacham contends that our democracy makes progress when it is led by a president who can rise above his own personal flaws and limitations to pursue a destiny of greatness and state of universal opportunity that we have always been clearly able to describe even though we were mired in our imperfections and contradictions. We are a national example of continuous improvement that has generally been moving toward that vision of a society that embraces and enables the concept that all are created as equals and all should be able to pursue “life, liberty and happiness.”

He uses the Civil War to support the idea that we have often struggled mightily in conflict with one another over just what matters more, the rights of individuals, groups, or regions or a society where everyone is guaranteed an equal chance if not an equal outcome. Just how to operationalize such a grand idea has been a struggle and reasonable people see different paths. The process works when norms of engagement are respected and the resolutions of major differences are discerned through negotiated compromises.

We have faced the same issues several times over our short history. Issues like immigration policy, the pros and cons of public assistance, how to manage education for all, whether to provide for the health of every resident, and whether to isolate ourselves from the rest of the world or to be a leader in the search for worldwide peace. None of these topics are new issues. A major issue never clearly resolved, despite a Civil War, is what is controlled locally versus what is best managed nationally.

Meacham proposes that we have succeeded because we have the equivalent of an open and embracing soul that has been a beacon for all people to see from around the world that goes back much further in time than 1776 or 1789. It is true that this vast continent was taken from its original occupants who were often cruelly displaced, and much of our great nation was built utilizing the efforts of enslaved people. The original concepts of “life, liberty, and happiness” did not apply to native people, the enslaved, or to women. It was a society built for white men and secondarily offered to women. He quotes Sojourner Truth, a freed slave, suffragette, and feminist, from the 1850s who is reported to have said at the Women’s Rights Convention in Akron, Ohio in 1851:

I think ‘twixt the Negroes of the South and the women of the North, all talking about rights, the white men will be in a fix pretty soon.

Sojourner Truth was a woman whose voice still has much wisdom for us now more than a hundred and fifty years later. Check out some of the things she said. One quote seems to me to be closely linked to what Meacham calls the “soul of America.”

Let ... individuals make the most of what God has given them, have their neighbors do the same, and then do all they can to serve each other. There is no use in one man, or one nation, to try to do or be everything. It is a good thing to be dependent on each other for something, it makes us civil and peaceable.

Meacham’s reassurance has some built in reservations. He says that his concern is that the vision of a just world for all, the norms and the leadership that have preserved us despite the abuses to the vulnerable at our origin, and the continuing struggle to extend the dream of opportunity to everyone that motivated so many over the decades like Sojourner Truth and Eleanor Roosevelt, now face the challenges of a complex world again. What is different this time is that we are without the leadership of a president who can rise above his own concerns and human frailties. In other times we have had leaders that reminded us of the validity of our vision and put the collective concerns of all of us above the concerns of his “base.” Meacham is clear about the fact that Trump is no Lincoln, no Teddy Roosevelt, no FDR, no Truman, no LBJ, no Reagan, and not a man of the statue and integrity of either President Bush. All of these men had documented shortcomings, but they all in their own flawed ways sought the “better angels” of our grand and incompletely realized vision. We can only hope that in time the incombent will follow their example.

Meacham puts it all together at a compelling level when he describes his reason for writing at this time about the presidency, and for focusing on what he describes as the soul of America.

"I have chosen to consider the American soul more than the American Creed because there is a significant difference between professing adherence to a set of beliefs and acting upon them. The war between the ideal and the real, between what’s right and what’s convenient, between the larger good and personal interest is the contest that unfolds in the soul of every American. The creed of which Myrdal and Schlesinger and others have long spoken can find concrete expression only once individuals in the arena choose to side with the angels. That is a decision that must come from the soul—and sometimes the soul’s darker forces win out over its nobler ones. The message of Martin Luther King, Jr.—that we should be judged on the content of our character, not on the color of our skin—dwells in the American soul; so does the menace of the Ku Klux Klan. History hangs precariously in the balance between such extremes. Our fate is contingent upon which element—that of hope or that of fear—emerges triumphant."

Just a few pages later he completes his thought about why he is writing in a way that brings me back to our shared concerns about healthcare.

"To know what has come before is to be armed against despair. If the men and women of the past, with all their flaws and limitations and ambitions and appetites, could press on through ignorance and superstition, racism and sexism, selfishness and greed, to create a freer, stronger nation, then perhaps we, too, can right wrongs and take another step toward that most enchanting and elusive of destinations: a more perfect Union."

For more than eighty years we have struggled in a slow back and forth way that has gradually moved us toward more equity in health. The majority of Americans now believe that they are entitled to some education, clean water, breathable air that does not cause cancer, and healthcare that supports their pursuit of “life, liberty, and happiness.” As Meacham describes, the “soul of America” and its pursuit of equal opportunity, or a more perfect union, is challenged once again. He reminds us of Lincoln’s words at Gettysburg in November 1863, five months after the great battle that left as many as 50,000 dead, wounded or missing. You remember what he said:

Fourscore and seven years ago our fathers brought forth, on this continent, a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived, and so dedicated, can long endure.

For more than four decades we have been pursuing a corollary to the “proposition that all men are created equal.” Is everyone entitled to the health that allows them to pursue life, liberty, and happiness? It is not a settled question. We know that leadership is important. What has been gained can be lost. Giving Atul Gawande an opportunity to model innovations that might support another step toward that dream is a wonderful opportunity. The election this fall will also be an opportunity for each of us to weigh in on how we feel about health and the “Soul of America.” I am very happy that such a thoughtful commentator as Jon Meacham has reminded us that we have rejected the merchants of self interest and purveyors of fear in the past and that we have the choice to do it again.



I’m Most Happy at the Lake

I’ve done a lot of traveling in the last month. As I look at the calendar now, I am delighted to see that except for the occasional trip to Boston to see the Red Sox play, attend a board meeting, or see one of my doctors, I will at home for the rest of the summer. In the end, traveling is always hard even if it takes you to see interesting places or renews connections with old friends and family. The older we get the harder it becomes.

What was planned as a fabulous triple purpose event, a combination family union, Father’s Day celebration, and an the introduction of my brother’s new wife to the extended family, was spoiled by computer system failures at an American Airlines subsidiary.

If you did not travel over the Father’s Day weekend you probably did not hear about the disruption to travel experienced by thousands of people because of a computer failure at PSA, a wholly owned subsidiary of American Airlines operating as American Eagle. More than 100 flights into Charlotte, North Carolina were cancelled last Friday. I awoke on Friday morning to find an email sent at 1:40 AM saying that our flight to Charlotte at 12:30 PM was cancelled, and that we had been rebooked on a flight to Charlotte the following Monday, the day after the important weekend, the day I was booked to return from Charlotte. Friday was a long day. We finally arrived in Charlotte at 7AM on Saturday. We were sleep deprived for a day we had anticipated for six months!

The trip down was not the end of our woes. American Airlines could not seem to resolve the problem and our trip back on Monday was cancelled on Sunday afternoon. We finally got a flight back to New Hampshire booked at 3:30 AM on Monday morning. We arrived back in New Hampshire at 11PM Monday night, and finally arrived home at about 12:30 AM Tuesday.

American Airlines does not have a deep understanding of customer service or “service recovery.” At 5:30 on Friday after waiting at a gate in Manchester for over four hours we were put in a limousine along with two other passengers to take us to Boston where American had a flight to Charlotte that was not on the regional carrier, but on the unaffected main part of American’s fleet. Driving to Boston down I 93 is a challenge at any hour, but late on Friday it is like visiting a chain of parking lots. Despite the delays we arrived at terminal B at 6:45. We had assigned seats and boarding passes, but the agent did not know we were coming and would not take our baggage and allow us to go through TSA and board a plane that would have needed to be held at the gate for only 5 or 10 minutes.

After a vigorous conversation he booked us on a flight at 5 AM Saturday morning and sent us to a hotel near the airport. The trip back was through Philadelphia, an airport I always try to avoid. This time we waited over an hour after landing to get to a gate. When the gate was finally opened, we sat another 15 minutes waiting for a fuel truck to leave that was blocking our gate while it fueled a plane at the adjacent gate. On Tuesday I received a form letter from the CEO that offered no explanations, but did grant me an apology in the form of 15,000 miles for my frequent flyer account. I think I will be booking on Southwest Airlines in the future.

The misery of the weekend did not totally negate the pleasure of seeing family, especially my two grandsons, ages “3 and ¾” and nine months. It did remind me of many of the issues that our patients face everyday. Complex systems require engineering that anticipates potential failures. When failures occur, as they frequently do in complex interdependent systems, the system must have backup processes that are known by all the critical players and can be effectively employed. When I was a CEO we spent significant resources backing up our systems. The managers who had the responsibility of maintaining order would spring into action when systems went down. They communicated effectively across our broad network because they knew that the failure might impact as many 900,000 patients. When order was restored the event was “autopsied” and lessons learned were applied for future events. We tracked the number of hours that our systems were “down” and incrementally moved toward “never.” We accepted the expense of duplicated systems so that we could recover from any disruption within minutes.

A computer problem that takes more than 72 hours to resolve is hard to understand. There was no weather problem, and nothing was wrong with the planes. Perhaps some hackers had frozen the system and were asking for a “bitcoin” ransom. What was really hard to understand was that the explanation offered was that the “corrupted system” was the one that managed the deployment of flight crews and flight plans. Perhaps if American Airlines does not want to spend the money on backup systems, a manual “work around” for such mundane tasks might be planned to avoid such large delays in the future.

I am sure that the customer service staff in the airports and on the telephones will remember the the weekend as a disaster for them also. We only encountered one rude individual. She was the woman in Boston who was checking in our bags at 3:30 for the 5 AM flight that finally got us to Charlotte. My guess is that being rude and using controlling behavior in a self protective way is a process she mastered long ago, or that the weekend was the final straw that pushed her into a state of burnout. To make the transaction work we accommodated her need rather than her extending herself to mitigate and understand our concerns. Again, I expect that sort of transaction might occur in healthcare as well. It doesn’t take much to destroy a “customer centric” facade when systems fail.

You might imagine my joy on Tuesday morning when I awoke realizing that I was in my own bed. I looked out the window at the lake and realized how lucky I was despite the fact that we were driving to Boston that evening for the celebration of Rick Lopez’s retirement from Atrius Health and its predecessor organizations where he has been a valuable contributor for over 36 years. Going to retirement parties is the only corporate activity of a CEO Emeritus. It was a joy to be celebrating Rick’s work. No other person I know has contributed more to the quality and safety that is taken for granted by the hundreds of thousands of people who get their care at Atrius Health. Perhaps American Airlines should hire Rick to apply his knowledge of systems engineering to their shabby operation.

The picture in today’s header explains why I am so content and lucky to be at home on my lake. It is a screenshot taken from a video of drone photography produced by a neighbor. My place, as is true for all the homes, is obscured by trees. It is located where the shore line meets the right side of the image. You can see “big” Lake Sunapee and Mount Sunapee behind us.

If you are traveling this weekend, I hope all goes well and there are no delays. If, like me, you will be lucky enough to be at home, count it as a blessing and don’t miss the opportunity to be out and about appreciating where you live, and your health that you may take for granted. We live in a complex world at a difficult time. A good strategy for survival is to name and embrace what you love and what sustains you.

Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

Gene

Dr. Gene Lindsey
The Healthcare Musings Archive

Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:

www.getresponse.com/archive/strategy_healthcare


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